The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TWO RIVERS BEHAVIORAL HEALTH SYSTEM 5121 RAYTOWN ROAD KANSAS CITY, MO Aug. 8, 2014
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review and policy review the facility failed to:
- Adequately assess/monitor patients for risk of elopement (when a patient leaves the hospital without permission), for three patients (#1, #2, and #5) of five patients reviewed.
- Adequately review and/or utilize patients' histories of being a runaway, having a prior elopement, or being in the custody of authorities, to assess elopement risk, for two patients (#1 and #2) of two patients who eloped.
- Elicit additional, helpful information from staff/patients overhearing a possible elopement plan by Patients #1 and #2, to possibly prevent the elopement.
- Thoroughly investigate, re-assess current patient risk and put education and/or interventions in place to prevent elopement for those at risk.
- Provide appropriate education and monitoring for facility identification badge practices.
The facility census was 47.

This failure had the potential to place 47 patients at risk for potential elopement. The facility failed to appropriately respond with preventive measures and education to prevent further elopements; it placed the patients at immediate risk for their health and safety, also known as immediate jeopardy (IJ).

On 08/08/14, prior to the surveyor team exit, the facility provided a plan of correction sufficient to abate the IJ by immediately implementing the following:
-To revise forms and initiate Policies and Procedures to prevent further elopements from the facility.
-To train staff and physicians in the changes in forms and Policies and Procedures by the following shift.
-Staff badges were deactivated by 08/08/14 which required all entrance to units by staff electronically unlocking doors from the nurses station.
-All current patients will be assessed for risk of elopement.
-A Root Cause Analysis will be initiated for all elopements occurring since 04/01/14 and all further elopements.
-An escort policy and patient phone policy will be developed.
All components of the plan of correction completed by 08/18/14.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observation, interview, record review, and policy review the facility failed to:
- Adequately assess/monitor patients for risk of elopement (when a patient leaves the hospital without permission), for three patients (#1, #2 and #5) of five patients reviewed.
- Adequately review and/or utilize patients' histories of being a runaway, having a prior elopement, or being in the custody of authorities, to assess elopement risk, for two patients (#1 and #2) of five patients reviewed.
-Provide direction regarding patient to staff ratio during patient off-unit transport.
-Follow the direction that Patient #1 was to have only monitored phone calls with his mother (mother did not have custody).
-Elicit additional, helpful information from staff/patients overhearing a possible elopement plan by Patients #1 and #2, to possibly prevent the elopement.
-Thoroughly investigate, re-assess current patient risk and put education and/or interventions in place to prevent elopement for those at risk.
-Completely and thoroughly educate staff in facility safe identification badge practices.
-Provide direction to staff for safe transport of patients when outside of the Modules (patient units.)
These failures had the potential to affect all patients in this facility, as elopement allows patients at risk to harm themselves and/or others. The facility census was 47, 10 of which were on Module (Mod) C, the adolescent unit; 13 on Mod B, the adult unit and 24 on Mod A, the trauma unit.

Findings included:

1. Record review of the facility's policy titled, "Nursing Assessment & Reassessment," revised 08/12, showed the following:
- Nurses collect data during the nursing assessment in order to determine patient's nursing care needs. Staff analyze this information and develop a treatment plan unique to each patient's needs.
- All spaces of the assessment are to be completed.
- A Registered Nurse (RN) completes a pain assessment, psychosocial assessment, fall risk assessment, functional assessment, nutritional screening, spiritual and cultural needs, language and cognition, learning needs and preferences. (No mention of an elopement assessment).
- The RN reassesses the patient every 12-hours, or when a patient's behavior changes, or any other occasion as warranted by the patient's behavior or condition.
- The treatment plan will be updated in response to any behavior change.

Record review of the facility's policy titled, "Elopement Prevention," revised 05/14, showed the following:
- Assessment and Referral Center (ARC-intake/admissions staff) will inform the admitting RN of any suspected elopement risk.
- The admitting RN will contact the attending physician for an order for Elopement Precautions (EP).
- The RN will initiate a treatment plan, considering appropriate interventions such as:
a. One-on-one monitoring (1:1);
b. Exits/doors monitored;
c. Restrict the patient to the unit.

Record review of the facility's policy titled, "Intake and Admissions," revised 02/14, showed that if the patient is admitted , the ARC staff verbally hand-off report to an RN on the patient care unit whereby the patient will be admitted . Information on the High Risk Notification Alert form (part of the assessment) will be reviewed with the accepting RN.

2. Observation, concurrent interview, and review of video surveillance on 08/07/14, at 2:00 PM, showed the following:
- Mod C was a 25-bed adolescent unit housing psychiatric patients aged five to 18.
- The unit was locked with staff having an identification badge that they swiped (electronic) to unlock the exit doors.
- Mod C was situated at one end of a long hallway and the entrance to a gymnasium (gym) was toward the other end of the long hallway.
- The hallway had two electronic exits that lead to unsecured outside areas on the facility's property.
- Staff C, Risk Manager, did not know what the policy was for staff to patient ratio while escorting patients from Mod C to the gym and back. Staff C stated that there was no written policy regarding this procedure.

3. Record review of Patient #1's Discharge Summary (from a previous admission), dated 04/18/14, showed he had been admitted to the adolescent, Mod C psychiatric unit on 04/11/14 because he was planning a suicide (thoughts of self-harm).

Record review of a Psychiatric Evaluation, dated 04/12/14, showed the patient had run away from a boys' home, and was brought to this hospital (this is a future elopement risk factor).

Record review of Patient #1's Intake Assessment (this current admission), dated 07/29/14, showed the following:
- He was admitted to Mod C on that date because he was suicidal and hearing voices to kill/hurt others.
- Patient #1 had been in the custody of a detention center for a crime (this is a future elopement risk factor as patients typically do not want to return to detention).
- The patient had a behavior of "running away." (This is a future elopement risk factor).
- ARC staff failed to identify the patient had a history of elopement on the assessment (it was blank), and documented the patient was NOT an elopement risk. No further elopement assessment was completed.

Record review of Admission Orders, dated 07/30/14, showed no orders for elopement precautions.

Record review of a Visitor and Phone Call log, dated 07/30/14, showed the patient could place calls to his mother, but they must be supervised on a speaker phone.

Record review of Nursing Progress Notes, from 07/30/14 through 08/04/14, showed the following:
- Patient #1 had been agitated, banging his fists on the floor, multiple times saying, "I just miss my mom." The patient told the nurse that maybe if he went to an ED (this facility had no ED so the patient would have to be sent off-site) for an exam on his hands, he would get to see his mom. (This could be a future elopement risk factor).
- The patient made multiple comments about how he was worried about his mom.
- There was no evidence the ARC nurse and the accepting RN collaborated information via the verbal report at admission.
- There was no evidence ARC staff and the accepting RN reviewed the High Risk Notification Alert form together regarding Patient #1.
- Patient #1 and five peers went to the gym at 8:00 PM. Patient #1 eloped with a male peer (Patient #2) as they returned from the gym.

Record review of Patient #1's Treatment Plan on 08/08/14, dated 07/30/14, showed staff failed to identify a potential for elopement even though Patient #1 had a history of elopement from a boys' home just four months prior.

4. During an interview on 08/08/14, at 1:34 PM, Staff I, RN Charge Nurse, stated that:
- Patient #1 could receive phone calls from his mother (at appropriate times), but only under supervision and via speaker phone.
- Staff I came on duty at approximately 7:00 PM on 08/04/14 and saw Patients #1 and #2 talking on the telephone with someone. They were not on speaker phone, and were not being supervised.
- She overheard the words, "Mom, or ma," spoken so believed they were talking with Patient #1's mother.
- Staff I could not explain why the phone call was made without staff supervision or speaker phone.

5. Record review of Patient #2's Intake Assessment, dated 07/31/14, showed the following:
- He was admitted to Mod C on that date because he had been running away from his father's home and was found walking down the middle of a busy four lane highway (suicidal).
- The patient was considered a high risk for suicide.
- ARC staff failed to identify the patient had a history of running away on the assessment (it was blank), and documented the patient was NOT an elopement risk. No further elopement assessment was completed.

Record review of Patient #2's Treatment Plan on 08/08/14, dated 07/31/14, showed staff failed to identify a potential for elopement even though Patient #2 had a history of running away.

6. During an interview on 08/07/14 at 1:30 PM, Staffs A, Chief Nursing Officer (CNO); B, Chief Executive Officer (CEO); and C, Risk Manager stated that:
- On 08/04/14, at approximately 8:30 PM, the Technician (Tech-Staff H) assigned to escort the patients (a total of six) to/from the gym was getting ready to swipe her identification badge at the Mod C doors when Patient #2 took her badge from her and ran down the long hallway back toward the gym. Staff H ran after Patient #2.
- Patient #1 ran down the hallway and passed Staff H.
- Patient #2 swiped the badge at the exit doors and both patients ran out the doors toward the nearest roadway.
- Earlier in the day, both patients (#1 and #2) were seen/heard talking to Patient #1's mother on the phone prior to the elopement, possibly planning the elopement because some verbiage about needing a badge to get out (of the building) was mentioned during the phone call.
- Patient #1 was scheduled to go to court the next day (08/05/14) and did not want to go (could be considered an elopement risk factor).
- They believed both patients ran to Patient #1's mother's home nearby.

During an interview on 08/08/14, at 1:34 AM, Staff I, RN Charge Nurse, stated that:
- She was on duty during the elopement of Patients #1 and #2.
- She heard Staff H (Tech) yelling, "No, no."
- She went to the Mod C doors looked out and saw Patients #1 and #2 running down the hallway, back toward the gym.
- She opened the Mod C doors and let the other four patients back into the unit.
- The other patients told her the patients had been planning on running so she ran down the hallway after Patients #1 and #2. Staff H told her the patients ran off the property.
- She (Staff I) went outside to check around for the patients. They were not found.
- She was not aware of Patient #1's prior elopement history. She did know this was the third admission for Patient #1.
- She stated there was no written policy regarding escorting patients off the unit.
- She stated there was no nursing risk assessment for elopement. The admissions/ARC staff assessed for elopement risk, reported the risk to the physician and to the admitting nurse.
- Patient #2 was overheard saying something about "having to get their badges," sometime prior to the elopement. She failed to question Patient #2 about these comments, or update the treatment plan to prevent possible badge theft and/or elopement.
- She had not been interviewed by administrative staff about her knowledge regarding this elopement (for the investigation).

During an interview on 08/08/14, at 8:54 AM, Staff L, Director of Admissions, stated that Admission/ARC staff were responsible for obtaining the initial patient history, and assessment of elopement risk. All staff were responsible for obtaining further history via the past admissions, interview of family and patients and staff was to incorporate this history into the treatment plan.

During an interview on 08/08/14, at 9:04 AM, Staff G, Psychiatrist (for both patients), stated the following:
- Physician's orders for elopement precautions were based on staff recommendations.
- Intake/ARC staff do the initial assessment and make recommendations for risk precautions.
- Staff G was aware of Patient #1's previous elopement, and probable return to detention.
- The Physician was responsible for precautions after the admission process.

During an interview on 08/08/14, at 10:10 AM, Staff M, RN Manager of Mod C, stated that:
- Intake/ARC staff recommended precautions and called the physician for orders.
- Intake/ARC staff or the physician usually requested any prior admission records for review.
- Patient #1 came from a detention center and Patient #2 was in the custody of the State.
- Staff M agreed elopement risk factors included prior running away, prior elopement, and being in a detention center.
- All patients on Mod C had not been reassessed for elopement risk as of this time (time of interview.)

During an interview on 08/08/14, at 11:10 AM, Patient #3, stated the following:
- At about 8:00 PM on 08/04/14, Patients #1 and #2 said, "We're going to run tonight, we were going to last night."
- Patients #1 and #2 asked Patient #3 to distract the Tech so they could get her badge.
- Patient #3 told them she could not do that.
- Six patients (including Patients #1 and #2) left the gym that night at about 8:30 PM, when the Tech scanned her badge at the Mod C doorway, Patient #2 took her badge and ran. Patient #1 ran too.
- Patient #3 said she had overheard Patients #1 and #2 planning (did not remember when) to go to Patient #1's mother's house They said they would cut their hair off, get high because Patient #1's mother used drugs, and change their names.

During an interview on 08/08/14, at approximately 2:40 PM, Staff E, Mobil Licensed Professional Counselor (Intake/ARC assessor), stated that her assessment was based on current (24-48 hours) information obtained by the patient, family, personnel or detention staff. Staff E knew Patient #2 had a history of being a runaway, but felt that was not a risk factor for elopement as, "Kids do that all the time."

During an interview on 08/13/14, at 9:04 AM, Staff H, Tech, stated that:
- On 08/04/14, at approximately 8:00 PM, the patients on Mod C were begging to go to the gym, so she took six of them, including Patients #1 and #2.
- While in the gym, two female patients were suspiciously watching her but she could not say why.
- At about 8:30 PM, when she returned the patients to Mod C, while swiping her badge to get into the unit, Patient #2 took her badge and ran down the hallway toward the exit door.
- Patient #1 said, "I'll help you catch him," and ran after Patient #2.
- She ran down the hallway after them both. When she reached the exit doors, she realized the two patients were gone so she headed back to Mod C.
- She intercepted Staff I, Charge Nurse, and told her the patients had eloped. Staff I went outside and looked for the patients.
- When she (Staff H) returned to Mod C, the two female patients that had been watching her in the gym told her Patients #1 and #2 had been planning on leaving and had asked the other Mod C patients if any of them wanted to go with them.

7. During an interview on 08/07/14 at 1:40 PM, Staff A, CNO, stated that all facility staff received education following Patient #1 and Patient #2's elopement. She stated that the educational content was on name badges only and that the name badges were changed to one that clips to a person's clothing. She could not provide any evidence (inservice records, etc.) of the staff that had received the training only that staff currently working had received the education. She also stated that Staff H (the Tech that had her name badge taken and swiped by Patient #2) had no follow up education because, "she followed policy".

During an interview on 08/07/14, at 4:12 PM, Staff A, CNO stated that she had not documented any education provided to staff since the elopement on 08/04/14. Staff A also confirmed there was no written policy regarding escorting patients off the units.

8. During an interview on 08/08/14 at 9:55 AM, Staff A, CNO, stated that she did education for the night shift staff by sending an email to explain the following:
- "Keys are to remain in your pocket at all times;
- Badges are to be clipped to your clothing using the provided badge holder;
- Badges are to be visible at all times;
- ABSOLUTELY NO LANYARDS (a cord usually worn around the neck to hold a badge or keys) are to be utilized for badges and/or keys providing access to secured areas or exits. All staff are required to sign documentation that they have been notified of this change. Please see your department manager for the sign in sheet". The email was signed by Staff B, Chief Executive Officer (CEO). Staff A stated that the email was not sent requesting a return receipt and she did not know if all staff had received the email or read their email.

9. Observation on 08/08/14 at 10:10 AM on Mod B with Staff R showed Staff V, RN, with keys hanging from her name badge.

During an interview on 08/08/14 at 10:10 AM on Mod B, Staff V stated that she had not opened her email that morning and wasn't aware that her keys were supposed to be in her pocket.

10. Observation on 08/08/14 at 10:15 AM on Mod B with Staff R showed Staff S, Licensed Practical Nurse (LPN), with keys hanging from her name badge.

During an interview on 08/08/14 at 10:15 AM on Mod B, Staff S stated that she had received training on the name badges with use of a clip type attachment. Staff S also stated that she had not opened her email that morning and wasn't aware that her keys were supposed to be in her pocket.

11. Observation on 08/08/14 at 10:35 AM on Mod A with Staff R showed Staff T, RN, Nurse Manager, with keys hanging from his name badge.

During an interview on 08/08/14 at 10:35 AM, Staff T, stated that he had received education on the name badges with use of a clip type attachment but hadn't had a chance to read his email that morning.

12. Observation on 08/08/14 at 10:40 AM on Mod A with Staff R showed Staff U, Patient Safety Technician (PST), with keys hanging from her name badge.

During an interview on 08/08/14 at 10:44 AM, Staff U stated that she had not received any education on the name badges because this was her first day back to work since the elopement incident.

13. Observation on 08/08/14 at 10:44 AM, showed Staff R, Nurse Manager Mod A, held up the printed email to Staff U and stated, "This is education, did you sign it?" Staff R also stated that the facility Dietitian came to the unit once per week and had group therapy with the patients.

14. During an interview on 08/07/14 at 1:40 PM, Staff A, CNO, stated that all facility staff received education on the name badges except dietary and housekeeping even though they wore badges and entered the modules.

15. Record review of Patient #5's Discharge Summary, dated 05/21/14, showed he was admitted to the Trauma Unit, Mod A, on 05/19/14 on the advice of his therapist because he expressed suicidal ideation with a plan to kill himself.

Record review of the High Risk Notification Alert, dated 05/19/14, showed that the patient was evaluated as a High Suicide Risk Level but had not been evaluated for Elopement Risk.

Record review of Patient #5's H&P, dated 05/19/14, showed the physician ordered that the patient be on a 1:1 (level of observation by another person to ensure safety) as needed.

Record review of a Psychiatric Evaluation, dated 05/20/14, showed the patient had been agitated, uncooperative, refused assistance with discharge planning and the psychiatrist advised the patient was to be put on a 96-hour hold (court ordered involuntary psychiatric admission).

Record review of the Psychiatrist Progress Note, dated 05/20/14, showed that staff reported the patient went out to smoke with other patients and staff and the patient jumped over the fence and eloped at 4:30 PM.

Record review of the Continuing Care Discharge Plan, dated 05/21/14, documentation showed, "Patient eloped on 05/20/14; didn't come back since then".

16. Interviews and observation on 08/08/14 of the courtyard fence in the smoking area outside of Mod A showed an air conditioner unit enclosed by a tall locked wooden fence. Staff R, RN, Nurse Manager Mod A, stated that the wooden fence was new as of Tuesday, 08/05/14. She stated that Patient #5 jumped on top of the air conditioner and then to the roof of the building and off of the premises. Staff Q, Director of Plant Operations, stated that a temporary orange construction fence had been placed around the air conditioning unit on 05/22/14 after Patient #5 used it to elope and that it was secure until the permanent fence was completed on 08/05/14.